Tracking the opioid crisis a challenge

Monday

It’s the beginning of December, and Chuck Kiessling can’t tell you how many opioid overdose deaths the 67 members of the Pennsylvania Coroners Association handled last year.

It’s not because there are too many to count – but that’s probably true, too, he said. It’s because there’s not enough manpower to finalize the association’s annual report. His best estimate lies around 4,880 statewide for the whole year, almost 240 more than the federal Drug Enforcement Administration detailed in a July report fueled by coroners’ reports.

And that’s a problem, DEA officials say.

“Our report, it quantifies what drug is responsible for deaths,” said Patrick Trainor, special agent for the DEA in Philadelphia. “In some counties, that drives a lot of our enforcement activities.”

The DEA estimates that in 2016, 13 people died of a drug overdose each day. In its July report, the DEA said that the lack of standardized overdose death data “inhibits timely analysis necessary for stakeholders to drive decision-making.”

But the number of people dying from opioid addiction is just one piece of a very complicated puzzle, law enforcement and public health officials say.

Frustrated officials

Despite an opioid crisis that’s claiming more and more lives every day, no one can say exactly how many people are affected by opioid addiction. There is no state database that tracks how many people seek detoxification treatment or arrests for possession or distribution of fentanyl, heroin or cocaine – the three deadliest drugs in Beaver County in 2016.

That’s a frustration for the public health and law enforcement officials who are trying to wrap their arms around what President Donald Trump this fall declared a public health emergency.

It took Beaver County District Attorney David Lozier to launch a study of county 911 calls to determine just how much the epidemic was impacting the community. Lozier was inspired by voters he met while campaigning door-to-door in 2015. Many begged him to do something about opioids.

“All of the experts say that we need to be analyzing our data as far as where things happen, what kinds of crimes are happening and do a better job of being proactive,” Lozier said. “This is every community, every school district.”

The 911 study actually showed on a map what Lozier had heard from residents: Drug overdoses were happening throughout nearly every municipality in the county — 1,112 in 2016 and through September 2017 — and about half were concentrated in the river communities of Beaver Falls, Ambridge, Aliquippa and New Brighton.

All of the experts say that we need to be analyzing our data as far as where things happen, what kinds of crimes are happening and do a better job of being proactive. This is every community, every school district.
David Lozier, Beaver County District Attorney

While deaths eventually have to be counted by the medical examiner as drug related, drug overdoses in which the person is revived are not counted by anyone.

“Overdoses that are not fatal are not currently reportable to anybody,” said Dr. Karen Hacker, director of the Allegheny County Health Department. “Nobody has to tell you that we've had this many people who've had nonfatal overdoses.”

That’s a problem, Hacker said. There’s no exhaustive list of nonfatal overdoses — and officials have no idea what drugs those who didn’t die from an overdose were using. In Beaver County, officials have been able to track the number of overdoses that could have been fatal through reports of the administration of naloxone — commonly called by its brand name Narcan — by first responders.

But not everyone who overdoses calls 911.

“We know that there's a lot of people who overdose that ... 911 never gets called,” Hacker said. “Somebody takes them into their house and gives them hot coffee or puts them in the shower or something like that. Or gives them Narcan.”

It’s a hole in the system, Hacker said, that no one officially tracks nonfatal overdoses.

There’s no repeat offenders in my office — you only die once. I think we need to be looking more at the number of addicted and push these people to treatment, not focus on those who already died.
Chuck Kiessling, president of the Pennsylvania Coroners Association

“People have talked about what it would take to make that a reportable condition, but then you're also talking about who would be reporting it,” Hacker said. “Would the EMS guys be reporting it? Would it just be hospitals?”

But cause of death is mandatory for reporting. And the DEA is willing to do whatever it has to do to get as detailed of information as possible to understand what is killing those with addiction. As elected officials in Pennsylvania, coroners are required to report a cause for every death. That is where the DEA is running into a brick wall trying to figure how what drugs are killing people.

Trainor said some coroners say they’ve been told by the state coroners association not to release the information, but officials from the association say that isn’t true.

“Some coroners are very, very cooperative in giving us data, and there are some that are not,” Trainor said. “Some we have had to serve with subpoenas to get stuff. Why? We don’t always get an explanation. Because they’re busy, some tell us.”

Kiessling, a nurse and paramedic who has served as coroner of Lycoming County for 18 years and is the current president of the Pennsylvania Coroners Association, said that’s true. Most elected coroners are part time, at best, he said, and as more and more people die from opioid overdoses, the workload gets heavier.

“Every coroner’s office is different in 67 counties,” Kiessling said. “Our resources are very different from county to county. Too many people have the CSI effect, where they think we bring a person into our facility and in 10 minutes have (all of the testing) back. We wait for days, weeks, months even for these reports to come back.”

And those reports aren’t always detailed enough for some officials. Pennsylvania Attorney General Josh Shapiro has been critical of the inconsistent and delayed data that has come from coroners' offices. During a roundtable discussion Nov. 30 in New Castle, Shapiro lamented that general standards on how overdose deaths are reported don’t exist.

He said he’s frustrated by the situation and underscored the importance of standardized reporting of overdose deaths so health and law enforcement officials can correctly identify where help is needed and for the public to be properly informed on what is going on in their communities. During the roundtable, Shapiro said he suspects there are more overdose-related deaths than the public realizes because of the issues facing coroners.

Shapiro’s press office would not provide any additional comments on the attorney general's statements.

"As Attorney General Shapiro noted last week at the roundtable in New Castle, it's important that the reporting of overdose deaths by coroners become more uniform, so that law enforcement and health officials have the most accurate data to respond to the epidemic in their communities," spokesman Joe Grace said in a statement.

Kiessling said he doesn’t understand the emphasis on overdose death data.

“The people that make it to my office, we can’t do anything for,” he said. “It isn’t going to impact the living.”

But it is, Trainor said. The data helps law enforcement and public health officials understand what drugs are killing people and what areas need the most help.

“It helps us to identify which areas are the hardest hit,” he said. “Which counties might need more Narcan than others, which counties are in need of more treatment resources. That report, it quantifies what drug is responsible for the deaths.”

Some additional information available

As time has gone on, more information has become available. Each coroner files an annual report that details the cause of death for every person who died in the previous year. In Beaver County, those reports have gotten more detailed as the years have passed.

Before 2012, annual coroner reports from the Beaver County coroner’s office filed at the prothonotary's office listed name, age, cause and manner of death. Often cause of death was listed as “combined drug intoxication,” “combined drug overdose” or “opiate intoxication” with no indication of what drug was involved. Later reports indicated the date of death, race and gender for those who died, but still sometimes didn’t include the drug linked to death.

It’s difficult to track the progression of drug addiction and death in the county when that detailed information isn’t available any further back than five years.

Those reports also don’t necessarily have updated information. A review of the report from 2011 lists 15 overdoses, but according to a story appearing in The Times in 2012, the coroner at the time, Teri Tatalovich-Rossi, said there were 32 overdose deaths that year.

Pending deaths — those that a cause of death isn’t finalized at the time of the report — aren’t regularly updated in Beaver County’s records. Even now, nearly a year later, the coroner’s report for 2016 lists 97 deaths — when coroner David Gabauer has publicly reported that there were 102.

The Times is awaiting a court date to defend its request for more detailed information about those who have died from drug overdoses from Gabauer, who denied a written request in January under the state’s Right to Know Law.

In Allegheny County, Hacker has scads of data at her fingertips. Her office began working with Allegheny County 911 to find out how many overdose calls local emergency services were handling.

That data isn’t confirmed until the patient is treated, she said, which means that there is a lot of work that needs to be done with the data. She agrees that overdose death data plays an important role in helping health and law enforcement officials figure out where to best send resources.

“I feel that one of the things that public health brings to the table is this concept of data-driven decision making,” Hacker said.

Thanks to data analysis, Hacker has been able to identify which parts of Allegheny County have the biggest drug problems and works with health and human service programs to send resources to those areas.

Manpower and information in Beaver County

Beaver County lacks the manpower that Allegheny County has, and Beaver County does not have its own health department, something not uncommon for smaller counties in the state.

Much of the heavy lifting on opioid overdose prevention falls on two county officials: Lozier and Kate Lowery, an administrator with Beaver County Behavioral Health’s drug and alcohol programs.

The crisis has Beaver County officials so overwhelmed that they often aren’t able to keep up with the data, Lowery has said. Lozier has helped create a system with Beaver County Emergency Services that, if maintained, could help law enforcement, public health officials and others have a better idea of where the crisis is at its worst.

Gabauer submits information to Overdose Free PA — an online database where coroners from across the state voluntarily submit demographic data on overdose deaths — but only when he has time to update the site. Beaver County’s 2017 overdose death numbers sat at 51 for several months. Two weeks after Gabauer provided The Times with third-quarter numbers — taking the year’s tally of overdose deaths through Sept. 30 to 63 — Overdose Free PA still showed just 51. However, as of Friday, the site indicated there had been 58 overdoses, but no indication of what time frame that is through.

At an October community meeting at South Side Area School District, Lowery told attendees that public health officials had no idea how many people have died of a drug overdose in the previous three months.

“… If we go back to 2012, we've lost 279 lives combined through June of this year,” Lowery said. “And that's not this third quarter of the year; we haven't begun to enter that data.”

A month later, Gabauer released third-quarter numbers, which showed a slowdown in drug overdose deaths.

Having better data on where, when and how people are overdosing is critical to solving the crisis, Lozier said. Before Lozier called for the 911 study, police and EMS workers had an anecdotal idea of where overdoses were occurring, but no hard data.

The study has changed things, Lozier said. Dispatchers now flag calls that are suspected as an overdose. That list is cross-checked with the emergency agencies who responded, and, ultimately, the 911 center has an idea of how many overdoses occurred each month and where. That information, once finalized, is shared with law enforcement.

It’s a challenge, ensuring that 55 municipalities, 34 police departments, numerous ambulance companies and the coroner are all working together, Lozier said — especially when they’re being governed by “antiquated” laws. But the agencies know there’s a benefit to sharing their data and working together, he said.

“They all know this needs to be done, and they’ve been working very hard together to gather this data,” Lozier said. “Some police departments had data on their own, but no way to share it. Now we can draw a bigger picture, as detailed as possible.”

Lozier said he doesn’t know what impact the study and its ensuing data is going to make. It’s a tool the county will give to the municipalities and law enforcement, but what they do with it is ultimately their choice, he said.

“Are they going to work together more than they have in the past? Are they going to change how they police in their department?” Lozier asked. “I don’t know. All I can do is give them the tools. It’s up to them to come forward.”

While public health and law enforcement officials are adamant that there is something to be learned from who is dying from opioid use, Kiessling isn’t convinced the data can help the cause.

“There’s no repeat offenders in my office — you only die once,” he said. “I think we need to be looking more at the number of addicted and push these people to treatment, not focus on those who already died.”

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